Patient Information
Name: Carolyn Cross
Age: 41 years
Gender: Female
Setting: Outpatient Primary Care Clinic
Chief Complaint: Well-woman examination and concern about
breast cancer risk
Date of Visit: April 26, 2024
SubjectiveHistory of Present Illness (HPI):
Carolyn Cross, a 41-year-old Hispanic-American female, presents for a
routine well-woman examination. She is generally healthy with no
active medical complaints but expresses concern about her risk of
breast cancer due to recent diagnoses of intraductal breast cancer in
her mother (age 63) and maternal first cousin (age 44). She reports a
history of fibrocystic breast changes, describing her breasts as “lumpy”
for as long as she can remember, with mild tenderness around her
menstrual cycle. She performs regular self-breast examinations and
denies noticing any new lumps, nipple discharge, or skin changes. Her
last mammogram, performed 18 months ago at age 40, was normal
(report unavailable). Her last menstrual period was two weeks ago,
, with regular cycles every 25-26 days since menarche at age 10.5. She
denies intermenstrual bleeding, weight changes, fatigue, or other
systemic symptoms. She is particularly anxious about her family history
and seeks guidance on her breast cancer risk and preventive measures.
Past Medical History:
Fibrocystic breast changes, managed with vitamin E
supplementation (self-initiated).
No other chronic medical conditions.
Surgical: Bilateral tubal ligation at age 35 following second
delivery.
Obstetric: G2P2, two uncomplicated normal spontaneous vaginal
deliveries (NSVD), breastfed each child for 4 months.
Hospitalizations: Two, for childbirth.
Medications:
Vitamin E (dose unspecified) for fibrocystic breast changes.
Occasional ibuprofen for headaches.
Allergies: No known drug, food, or environmental
allergies.Immunizations: Up to date, including influenza and Tdap per
CDC guidelines.Family History:
Name: Carolyn Cross
Age: 41 years
Gender: Female
Setting: Outpatient Primary Care Clinic
Chief Complaint: Well-woman examination and concern about
breast cancer risk
Date of Visit: April 26, 2024
SubjectiveHistory of Present Illness (HPI):
Carolyn Cross, a 41-year-old Hispanic-American female, presents for a
routine well-woman examination. She is generally healthy with no
active medical complaints but expresses concern about her risk of
breast cancer due to recent diagnoses of intraductal breast cancer in
her mother (age 63) and maternal first cousin (age 44). She reports a
history of fibrocystic breast changes, describing her breasts as “lumpy”
for as long as she can remember, with mild tenderness around her
menstrual cycle. She performs regular self-breast examinations and
denies noticing any new lumps, nipple discharge, or skin changes. Her
last mammogram, performed 18 months ago at age 40, was normal
(report unavailable). Her last menstrual period was two weeks ago,
, with regular cycles every 25-26 days since menarche at age 10.5. She
denies intermenstrual bleeding, weight changes, fatigue, or other
systemic symptoms. She is particularly anxious about her family history
and seeks guidance on her breast cancer risk and preventive measures.
Past Medical History:
Fibrocystic breast changes, managed with vitamin E
supplementation (self-initiated).
No other chronic medical conditions.
Surgical: Bilateral tubal ligation at age 35 following second
delivery.
Obstetric: G2P2, two uncomplicated normal spontaneous vaginal
deliveries (NSVD), breastfed each child for 4 months.
Hospitalizations: Two, for childbirth.
Medications:
Vitamin E (dose unspecified) for fibrocystic breast changes.
Occasional ibuprofen for headaches.
Allergies: No known drug, food, or environmental
allergies.Immunizations: Up to date, including influenza and Tdap per
CDC guidelines.Family History:
